Author Question: A nurse is documenting a patient's breath sounds. Crackles are heard as: a. loud, low-pitched, ... (Read 35 times)

rmenurse · **on:** Jul 24, 2018

A nurse is documenting a patient's breath sounds. Crackles are heard as:

a. loud, low-pitched, coarse sounds.
b. high-pitched, musical squeaks.
c. dry, grating sounds on inspiration.
d. high-pitched, fine sounds at the end of inspiration.

Question 2

A new staff member is working with a client who is dying. A nurse evaluates that this new employee requires additional teaching when he or she is observed:

A. Limiting the family's visiting hours
B. Staying with the client and family as much as possible
C. Finding a quiet place for the family members to gather
D. Informing the family about expected changes in the client's status

Jevvish · **Reply #1 on:** Jul 24, 2018

Answer to Question 1

D
Fine crackles are high-pitched, fine, short, interrupted crackling sounds heard during the end of inspiration; they usually are not cleared with coughing. Rhonchi are loud, low-pitched, rumbling, coarse sounds heard most often during inspiration or expiration that may be cleared by coughing. Wheezes are high-pitched, continuous, musical sounds like a squeak heard continuously during inspiration or expiration; they are usually louder on expiration and do not clear with coughing. Pleural friction rub has a dry, grating quality heard best during inspiration; it does not clear with coughing and is heard loudest over the lower lateral anterior surface.

Answer to Question 2

A
A. Encourage client to engage in supportive relationships with family and friends. Affiliation with significant others offers hope and energizes client by remaining active in daily life. For clients in terminal stage of illness, support frequent visits with loves ones, review lifetime stories or photographs, help client engage in meaning-engendering projects such as organizing photo albums and writing journals.
B. When interacting with family, allow time for them to express grief. Use a problem-solving approach to help them identify their problems pertaining to caregiving. Lead through a step-by-step discussion of how to approach each problem. Encourage family to use available community resources (e.g., hospice, respite care.).
C. Find a private location or close the privacy curtains in hospital room. Privacy promotes a sense of comfort for client to reveal inner thoughts and feelings.
D. Offer information about the client's illness and correct any misunderstanding or misinformation; this minimizes misunderstanding that can add to client's anguish and discomfort.